Dear Therapists, 

When clients or patients seek out your care, they are putting a lot of trust in you to help them as they heal from their traumas. The trauma field has a history of anti-fat bias and anti-fatness, which according to Audrey Gordon (p.10 )[1] “…are umbrella terms that describe the attitudes, behaviors, and social systems that specifically marginalize, exclude, underserve and oppress fat bodies. They refer both to individual bigotry as well as institutional policies designed to marginalize fat people.” This letter is an offering of what your higher weight clients and patients need you to know in order to provide affirming and ethical care:

  • Fat bodies have always existed and will always exist. Fatness is not a sign of pathology and not something that needs to be changed. In fact, trying to do so is not only not possible; it’s harmful
  • Anti-fat bias or weight stigma is traumatic. When fat people are told to lose weight, told their body isn’t acceptable, are stigmatized about their body size, are bullied about their body size, etc., that is a trauma
  • Fatness is not a sign of trauma. Many fat people have no trauma history and many do, just as many thinner people have no history of trauma, and many do.
  • When working with fat clients who have a trauma history, weight loss should never be expected or a treatment goal. Fat clients who heal from trauma will typically remain fat clients. (Unless they do something disordered to lose weight. Fat people are often prescribed behaviors that are considered eating disordered in thinner people.)
  • Familiarize yourself with the physiology of weight loss and the decades worth of research that finds 1) there is no proven way for the vast majority of people to sustain weight loss and 2) weight cycling, often known as yo-yo dieting, increases body size over time, with one-third to two thirds of dieters ending up higher than their pre-diet weight. This is to acknowledge that dieting changes a person’s physiology; there is nothing wrong with being fat.[2]
  • People of all different body sizes can have all different eating disorders. When you are working with a fat person who has an eating disorder do not assume that they have binge eating disorder. If they do have binge eating disorder, which does have a higher association with complex trauma, do not mistake weight for a behavior (and remember that binge eating disorder usually includes restriction). 
  • Fat people can have “atypical” anorexia, which is anorexia in a higher weight body. They are actually malnourished and their bodies need renourishment, not prescriptions or congratulations for weight loss.
  • Do not talk about your own dieting behavior, dislike of your own body, fear of weight gain, etc. in front of your clients, especially your fat clients. This is anti-fat bias and will be harmful for all of your clients.
  • Do your own work to unpack your anti-fat bias. It’s not possible to live in this culture and not have anti-fat bias. Address yours so you don’t project it onto your clients. It will make you a better provider.
  • Language matters. The words “obese” and “overweight” are shame-based. If fat clients find the word “fat” triggering because of how it’s been used to shame them, neutral terms such as “higher weight” may be used.
  • Remember that clients of all sizes might come to your office and ask for help losing weight. Some fat clients may even say that they want help treating their trauma so that they can lose weight. Be clear in communicating that weight loss is not something you can help them with or focus on. Instead, you can help them treat their trauma and support them in taking care of their bodies, without a focus on weight loss.
  • If you cannot work with fat clients in an affirming and fat positive way, acknowledge your own limitations to the client so they do not blame themselves. It is better to be honest and refer fat clients to someone who can provide them affirming treatment than to attempt to treat them yourself.

Please carefully consider each of these items before working with fat clients. We know that you went into the trauma field to help people heal from trauma. Considering the above when making treatment decisions will decrease the likelihood of you harming your fat clients.

We’ve all been raised in diet culture, and anti-fat bias needs to be unlearned. We’ve included some helpful resources beneath our signature.

9th Annual Weight Stigma Conference

June 28-29th, Denver Colorado

Weight Stigma in the Trauma Field: Why it Happens & What We Can Do

Presented by: Judith Matz, LCSW & Rachel Millner, Psy.D.

Special thanks to conference attendees for their valuable input

RESOURCES:

Aubrey Gordon: What we Don’t Talk About When we Talk About Fat (2020)

Christy Harrison: Anti-Diet: Reclaim Your Time, Money, Well-Being and Happiness

Through Intuitive Eating (2019)

DaShaun Harrison: Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness (2021)

Judith Matz: Unlearning Weight Stigma: The Latest Science on Weight and Trauma (Psychotherapy Networker, January/February 2022)

Sabrina Strings: Fearing the Black Body: the Racial Origins of Fat Phobia (2019)

Implicit Bias Test: https://implicit.harvard.edu/implicit/selectatest.html

This letter may be reproduced in its entirety 

 © 2023. 

[1]Gordon, A. (2020). What we don’t talk about when we talk about fat. Beacon Press

[2]  Tylka TL, Annunziato RA, Burgard D, Daníelsdóttir S, Shuman E, Davis C, Calogero RM. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495. doi: 10.1155/2014/983495. Epub 2014 Jul 23. PMID: 25147734; PMCID: PMC4132299.

Dear Kids (especially higher weight kids), 

The American Academy of Pediatrics (the organization where lots of doctors who treat kids belong) made a big oops! If you’re anything like my kids, you probably think it’s pretty funny when adults mess up or make mistakes. Well, this one is a huge mistake and sadly it’s not a funny one because this mistake will harm lots of kids like yourself. You might already know what a pediatrician is because you probably go to one at least once a year. They are the people who are supposed to make sure you have all your vaccines and listen to your heart and make sure your reflexes are working well. They are supposed to be people that you can trust to help you feel good about yourself and who will answer questions you have about your body and ways that it changes during childhood and adolescence. 

Well, this group of lots of doctors did something so wrong that it will actually lead to kids really disliking themselves or developing eating disorders, which are illnesses many people die from. It will also lead to lots of kids dieting and taking dangerous medications or having dangerous surgeries just to try and lose weight. I’m not so sure if they will ever apologize for their harm, but as a psychologist (a kind of doctor who helps people with their feelings) who works with lots of kids and adolescents and lots of people with eating disorders, I am going to apologize to you. Sometimes we say we are sorry even when we aren’t the ones who did something wrong because we are sorry that people are going to be hurt. And in this case I am so sorry that they got it so wrong and that you might be harmed as a result. 

Let me tell you a little about what these pediatricians did. I’m sure that you’ve heard from the grown ups in your life how people come in all different shapes and sizes and that each of us is unique and different and how that’s a really cool thing. Well, these pediatricians are saying that being in a bigger body is a disease, which if you think about it makes no sense. How can body size be a disease? That’s like saying foot size or how tall you are could be a disease. Once they say that being in a higher weight body is a disease, they tell us that we should use the BMI to see if someone falls into that higher weight range. Here’s the thing- they recommend using the BMI even though there are years of data that says the BMI is useless and racist. It’s actually a math equation. Not something that can diagnose a disease. These doctors even say that they use BMI because it’s easy to use and inexpensive. Have you ever gotten in trouble for taking the easy way out? Well, let’s just say that using the BMI is the easy way out- especially when they didn’t even tell the whole truth about it. 

So anyway, these doctors wrote a very long paper (like 100 pages long!) about trying to make higher weight kids into lower weight kids and many times throughout the paper they talk about something called weight stigma. You may or may not have heard of it, but in case you haven’t, weight stigma is basically when people are unkind or treat you differently because you’re fat or because they are afraid you will become fat. The thing about weight stigma is that it is really hurtful to people. It not only hurts people’s feelings, but it puts them in danger of eating disorders and depression and spending a lot of time dieting. The American Academy of Pediatrics is doing something that is pretty tricky because they are trying to tell everyone that weight stigma is bad (which it is!) while also stigmatizing people about their weight. They want to fool us into thinking that they are trying to be nice to fat people, but really what they are trying to do is stop people from being fat. How can you be nice to someone that you’re trying to change so much?!? It makes no sense. 

The other thing they are doing that’s very tricky is not telling the whole truth in their guidelines. I am sure that you’ve already been taught the difference between truth and lies, but have you ever had a grown up ask you a question and you told a little part of the story, but not the part that you knew was going to get you into the most trouble? That’s kind of what they are doing. They are telling a little bit of the story, but leaving out the details that would get them in the most trouble and they are hoping no one will notice, but we noticed. They are leaving out that lots of their members are making money from telling kids to use medications or have surgery to lose weight. They are also letting us know about some research, but leaving out lots of research that disagrees with the things they are trying to say. In fact, lots of times in their (long) paper they give a recommendation and then right after say that there’s no research to support it. 

Ok, so what we know so far is that these pediatricians first said that body size is a disease, which makes no sense. Then they used an outdated and racist equation to decide which bodies meet the criteria for the supposed disease and then they pretend they are being nice to higher weight people when really they are trying to make higher weight bodies not exist anymore and then they are lying about the research. None of this sounds very trustworthy, does it? But they don’t stop there with their half truths and misinformation. They keep going and start talking about what makes some bodies bigger than others. It’s kind of a weird thing to talk about when you think about it. Of course some bodies are bigger than others just like some people are taller than others and some people have different color eyes than others. But they don’t care about that. If you look back on pictures of people from any generation- like even really old pictures from like 100 years ago you will see some bigger bodies and some smaller bodies. That’s because higher weight people always existed and they always will and thank goodness for that. It would be super boring if everyone was the same size and really sad if higher weight people didn’t exist. 

In their very long list of what makes some people bigger than others, they talk about these things called social determinants of health. Social determinants of health are things like if we have access to enough food, if we live in a place that’s safe and can go outside and play, if we have grocery stores with all different foods available, if we can get to the doctor regularly, if we are being oppressed or marginalized (which ironically is what the pediatricians are doing to higher weight people), if we have enough money to buy things that we need, if our schools are safe. Really important things, right? And things that have a pretty big impact on our health and well-being. Most of you reading this are probably thinking that this would be the time these pediatricians would stop talking about making bigger bodies smaller and start talking about how to end poverty and make sure schools are safe and that kids can see them for a check- up every year because if these doctors put time and thought into that they could really improve the health of kids. Instead they just keep going on with their weight stigma. 

This is where things start to get even more upsetting because the pediatricians start talking about their ideas for how to make higher weight people smaller. What’s really confusing to me and maybe to you as well, is that there’s lots of research that tells us that almost everybody who loses weight gains it back (because bodies are super smart and don’t like to be malnourished) and that people who gain and lose weight a bunch of times are more likely to have health problems, and even these doctors tell us that as soon as people stop with the “treatment” they are receiving, they start to gain weight back. In their own words these doctors know that people are likely to lose weight and then gain it back and if they keep coming back for more treatment that’s going to happen over and over. And on top of that, the treatments they are offering are kind of scary and dangerous and put kids at risk for lots of yucky side effects that could make it really hard for kids to do kid things like play and go to school. So that’s why I get confused- these pediatricians say they are trying to help kids, but so far it seems like they are not doing a very good job at it. 

I’m not going to go into too much detail about the ideas these pediatricians have because I think it’s pretty harmful for kids to even hear this stuff being talked about, but there’s a couple of things I think it’s important for you to know. When they share these ideas they let us know that they don’t really know how these ideas will impact kids’ mental health (mental health is kind of like physical health but about thoughts and feelings). I don’t know about you, but to me it seems pretty important to know how something is going to make kids feel before suggesting it to them. In their second idea, the pediatricians talk about some medications to give to kids. It was scary to learn that a lot of these medications aren’t even approved for kids to use to lose weight and many of them help with various other illnesses that kids get. It would be really awful if someone who actually needed the medication couldn’t get it because it was being wasted on trying to get kids to lose weight. It was also really scary to see that the pediatricians tell us that there’s no evidence for using these medications in this manner. It seems like they are trying so hard to find a reason to prescribe these medications. I’m a psychologist not a detective, but I wonder if we went looking if we might find some of these doctors make money from these medication companies. 

The other thing these doctors recommend is a surgery that basically takes a perfectly functioning organ (the stomach) and removes part of it. This is kind of like doing surgery on an arm that’s not broken- it not only makes no sense, but we would really question what a surgeon was thinking doing that operation. We have to wonder the same thing here. Why would doctors want to mess with a perfectly functioning organ in kids? And especially with a surgery that has a lot of risks (including death) and no evidence that it leads to weight loss long term. Some kids who have this surgery might have to have another one a few years later and some kids might not be able to get enough vitamins for their body to run properly. Again, I’m a psychologist not a detective, but I wonder if some investigating would discover that some of these doctors make money from these surgeries. I think there’s a pretty good possibility that’s the case. 

You might feel like you just read a book, but remember these doctors wrote like 100 pages, so this is kind of like cliff notes (I think those might be things that only old people like me remember, so if you don’t know what they are, look them up). All of the information in this letter to you is why I am here saying that I’m sorry. And it’s not just me that is here saying that it’s wrong- there are thousands of us working really hard (including lots of awesome pediatricians!) to try and get these guidelines tossed out and to let kids and adults know how harmful they are. No kid should have to be subjected to these things no matter what size their body is and it’s not ok that the American Academy of Pediatrics let you down so much. 

Here’s what’s super important for you to know: your body is just fine exactly as it is. You don’t need to lose weight. In fact, childhood and adolescence is a time when people should be growing and gaining weight. You have so many more important things to do in your lifetime than spend time trying to make your body smaller. It’s super dangerous and doesn’t work anyway. And it’s totally unnecessary. And in case no one told you (because a lot of these doctors and some other grown ups sometimes keep this a secret), it is totally possible to live a really wonderful and awesome life in a fat body. There are so many kids and grown ups doing just that right now! Your body is on your side. No need to fight it. 

Sending you love and hope for a future where all kids feel free in their body,

Dr. Rachel Millner

I have been interviewed for many different podcasts, newspaper articles, magazine articles, and research studies, and have never been traumatized by the experience, that is, until I was interviewed for a podcast focused on trauma. I was a guest on the podcast to talk about the trauma of weight stigma. Specifically, the trauma of navigating a world that has a multi-billion dollar industry aimed at making a body like yours not exist anymore; a world in which you might be denied healthcare, given subpar care, be denied access to travel or activities, be harmed by therapists and the mental health system all because of the size of your body. The trauma of having your body labeled “protective” or a “shield” to prevent sexual advances because the concept of fat people being attractive is so beyond the capacity of many people to understand. 

This was a podcast I was excited to be on. A podcast that I thought would allow many more trauma therapists to understand the trauma of weight stigma and to, perhaps, be safer for fat clients. Except instead of having the opportunity to talk about the trauma of weight stigma, the host sounded a lot like the diet industry. The host was focused on why fatness is a problem and wanted to engage around body fat percentages instead of educating listeners about the trauma of weight stigma. The host wanted to argue about “health” and types of foods instead of hearing how healthism negatively impacts people and moralizing food is harmful. 

I found it particularly interesting that though this podcast took place over zoom and the host could clearly see that I am in a fat body, there was no pause to consider that perhaps talking negatively about fat bodies could be harmful to me as a fat person. In the end I asked that the podcast not be aired because, ironically, instead of educating listeners about the trauma of weight stigma the podcast would have traumatized higher weight people. I know many people might be wondering what podcast this was, but it ultimately doesn’t matter because it could have been any of them. The trauma field has a long history of traumatizing higher weight people. 

I could go back even further than this, but for the purpose of this blog, I am going to take you back forty years to the 1980s when the adverse childhood experience (ACE) study was completed leading to ACE scores. ACEs are one of the most common topics when trauma is discussed, but rarely does anyone mention how the original study came to be. Dr. Vincent Felitti who developed the ACEs worked at a weight loss clinic and noted that those he felt were most “successful” (i.e. losing the most weight) were most likely to drop out of the weight loss program. Dr. Felitti could not imagine why anyone would drop out of the program especially when they were losing so much weight, so he figured that there must be something ‘wrong’ with those people. Dr. Felitti found out that a subset of the people who dropped out of the study had been sexually abused and he could only conclude that those who dropped out of the weight loss program must be regaining weight in order to “protect” themselves from unwanted sexual advances. Of course, it did not occur to Dr. Felitti that fat people also deal with unwanted sexual advances or that those who were restricting the most were most likely to start bingeing and gain weight as their body wisely tried to bring them back to homeostasis. Or even that they didn’t want to waste their time at his weight loss clinic anymore or that he wasn’t a safe person because he would chastise them for weight gain. Felitti only considered that the reason someone might regain weight is to not be seen as attractive.

Felitti is just one in a long string of well-known trauma therapists, researchers, physicians, and authors to pathologize higher weight people. This was especially evident throughout the Covid pandemic. Gabor Mate in an interview on The Current, says “why are people o*ese? Because they eat junk food. Why do they eat junk food? Because they’re stressed and that’s how they soothe themselves. So the most stressed parts of the population were also most likely to get Covid.” The assumptions in this statement are endless and the lack of imagination is profound. As any researcher knows (although there is no actual research into this statement), if you have already decided you absolutely know the answer to the research question before the research is done, you have a biased research study. In an interview about his book The Body Keeps the Score, Bessel Van Der Kolk includes fatness among a list of things trauma survivors are “vulnerable to.” Also on this list are medical illnesses, drug and alcohol addiction and depression. He comments that fatness (as well as the other things on the list) impact “optimal functioning of the entire organism, and the capacity for self-regulation and self-care.” 

This narrative that fatness must be a response to trauma and a way to “protect” fat people from being seen as attractive has been carried forth by the trauma field ever since. They have added to the narrative that fat people are fat because they eat to soothe themselves in response to stress and trauma, and thus gain weight. Or perhaps people are fat because traumatized people engage in “high risk” behaviors and fatness is one of them. What the trauma field does not seem to consider is that perhaps people are fat just because size diversity is a thing. That perhaps fatness isn’t bad and we don’t need to try and investigate why people are fat. Or that perhaps the investigation into fatness is causing fat people trauma. They do not seem to consider that the trauma or trauma response is not fatness, but anti-fat bias and weight stigma. Being fat is not a trauma. Living in a world that is not safe for fat bodies is a trauma. It’s not fatness that needs to change. 

Since the trauma field is so singularly focused on seeing fatness as pathology, it is no surprise that it has extended to fat children. The trauma field theorizes that childhood trauma leads to fat children which then leads to fat adults, thus we need to prevent childhood trauma in order to decrease the number of fat people. There are a million reasons why preventing childhood trauma is important. Preventing fatness isn’t one of them. Instead of concerning themselves with decreasing the number of fat people, the trauma field could focus on decreasing weight stigma which would, you know, decrease the number of traumatized people. But that’s not what they are doing. 

It just takes a quick google search of trauma and higher weight people (except you would need to use the stigmatizing language of “o*esity” in your search) to see how obsessed the trauma field is with fatness, which makes the trauma field thoroughly unsafe for fat people. You can’t conceptualize fatness as a trauma, be searching for ways to extinguish fatness, and also be a safe place for fat people to land. It doesn’t work that way. Just like my fat body wasn’t safe in that podcast interview, it wouldn’t be safe with many trauma therapists and many popular trauma therapy books need to be read with caution because the vast majority of them discuss fatness as resulting from a trauma or being the trauma. 

Perhaps surprisingly to those in the trauma field, but unsurprisingly to most fat people, experiencing the trauma of anti-fat bias or weight stigma impacts people in the same ways any other trauma does. Also perhaps surprisingly to those in the trauma field, but unsurprisingly to most fat people, getting trauma treatment that correctly identifies weight stigma as the trauma and that does not pathologize fatness helps people heal from the trauma. It will not lead to fewer fat people. It will lead to fewer traumatized people. The trauma field needs to evolve to a place of not only being ok with that, but celebrating it. That’s what the field is all about, right? Helping people heal from trauma? 

I wish that in the moment of that podcast interview I had the wherewithal to pause the host and point out what was happening, but as is often the case in traumatic situations, I was being flooded and struggling to ground and stop the interview from progressing. If I had been able to, I hope I would have pointed out that what was playing out between the host and me was an example of exactly the type of trauma I was talking about and I would have asked the host to pause and stop defending their weight stigma, and instead listen to what I had to say. I would have reminded them that I am the expert on what it means to live in my fat body and to navigate the world in a fat body as well as an expert on the trauma of weight stigma and that the host and listeners had an opportunity to learn from me. 

What I would have liked to say on the podcast is this: it is hard to exist in a fat body in a world that hates fat bodies and it is so important that as trauma therapists we help people to recognize that their body is not the problem; that anti-fat bias is the problem. The trauma of weight stigma is systemic and seeps into every aspect of our lives including in the therapy room. Trying to turn fat people into thin people not only isn’t possible and causes harm, but is also traumatizing and that there are endless reasons people are fat and we don’t need to investigate them because there’s nothing wrong with fatness. As trauma therapists we have a responsibility to do our own learning and healing and to address our own weight stigma particularly because of all the ways anti-fat bias is embedded in the trauma field.

The trauma field explores the origins of trauma, the ways that trauma impacts people, and ways to support people in healing from trauma. What the trauma field as a whole has not done is look at themselves as the origin of trauma and when it comes to the trauma of weight stigma and anti-fat bias they are absolutely one of the origin points. The trauma field has an ethical responsibility to do better. After all, if you are causing trauma while trying to treat trauma, you aren’t breaking the cycle of trauma; you are perpetuating it. 

Dear therapist community during fat liberation month, 

As a psychologist, I spend a lot of time talking to other therapists and belong to quite a few therapist facebook groups. In a typical week in these groups, I see questions about how to support fat clients in losing weight, the use of stigmatizing language to describe higher weight people, healthist discussions about body size in which the claim is either it’s ok to be fat as long as healthy or it’s ok to promote weight loss when it’s for “health reasons,” and conversations about therapists pursuing weight loss and how they should respond to clients when they notice their weight loss. These posts usually lead to many responses that are aligned with anti-fat bias and telling anyone who comments in support of fat liberation that they are being “extreme,” “too hostile,” or unwilling to support their clients goals as if encouraging weight loss isn’t harmful if it’s what a client is wanting. 

Us therapists have a love of dialectics. We spend a lot of time holding the both/and for clients, sitting in the gray and pointing out “all or nothing” thinking. This may be helpful when exploring relationships, feelings, and decisions with clients, but it is harmful when it comes to oppression. The desire amongst therapists to see “both sides” when discussing oppression reveals that many therapists think that fat liberation and the oppression of fat people are two equally valid perspectives. The reality is that there is no room for debate when it comes to liberation. In conversations about fat liberation there are some absolute truths:

  • If you aren’t actively working on the liberation of fat people you are participating in our oppression 
  • If you promote weight loss you are promoting eating disorders
  • There is no way to support and encourage weight loss that isn’t oppressive and harmful
  • There is no such thing as a “healthy” way to pursue weight loss 
  • If, as a therapist, you are pursuing intentional weight loss- you are harming your clients- especially your fat clients
  • It is impossible to live in this culture and not have weight stigma and anti-fat bias. If you aren’t actively working to dismantle it you are perpetuating it

This list could go on and on. I know that many people reading this are already dismissing what I’m saying and leaning further into their convictions that the culture we have been indoctrinated into that tells us fatness is to be avoided at all costs, and fat people should all be pursuing thinness is correct and what we should all be aligned with. I know many people are thinking “but what about health,” or thinking some version of how they “feel better” when they’ve been in a smaller body so that must mean that weight loss is a good thing. It’s understandable if that’s the reaction you’re having. The intentional weight loss industry is a multi billion dollar a year industry that needs you to buy into it in order to keep making money. It is fascinating to me, though, that a field that has become more and more focused on “evidence based treatment” and “treatment goals,” loses all interest in the evidence when it comes to fatness. Therapists who have been trained to reduce harm are willing to cause harm in the name of thinness. 

I know that in the era of treatment goals that can be “measured and behaviorally described” there isn’t an easier one to complete your treatment plan with than weight loss. It’s the type of treatment goal that behavioral therapists love and insurance plans swoon over. So easily defined and measured. And so incredibly harmful and messed up. It will not be the rare client who, when going over treatment goals, names one that has something to do with weight loss. It is not an exaggeration to say that almost every person has wanted to lose weight at some point in their life and many are coming into therapy with this goal in mind. Our responsibility here is to be honest with our clients about what we can help with (healing their relationship with food and body, body liberation, etc.) and what we can’t (weight loss) and even with that open and honest conversation, clients are still going to talk about wanting to lose weight. And of course they do- our culture is steeped in anti-fat bias. It is absolutely possible (necessary) to support clients' body autonomy, hold space for their process, offer empathy, let them know you will be there for them and want to understand their lived experiences while also remaining clear and firm on your commitment to fat liberation. It’s not only possible; you have an obligation to do so. 

I know that there are therapists reading this who are thinking about their own desires to lose weight, some of whom are in fat bodies, and some of whom are not in fat bodies but would still like to lose weight. I support body autonomy as one of my core values, and I have a ton of empathy towards other fat therapists who are seeking weight loss. I understand how hard it is to exist in a fat body in this culture and how the pull towards weight loss can feel like such a relief and a way to distance ourselves from stigma and oppression. Sometimes we are being told we have to lose weight to access life saving surgeries. I know how complicated it is to be a fat therapist. For those therapists in smaller bodies who think they need to lose weight, or are attempting to maintain a body size that requires restriction or restraint in eating, I see you too and respect your body autonomy. 

And, what I want to name for all of us, is that while we get to have body autonomy we also need to recognize that what we are doing with our bodies and food when it comes to pursuing weight loss impacts our clients. If you are someone who is thinking ‘well I would never talk about my weight loss attempts with clients,’ consider other ways you are communicating your feelings about your own body and perspective on fatness. Are you someone who has food available in your office and refers to it as “healthy snacks?” Do you reference your clothes being tight or your body changing during covid in a negative way? When a client mentions their dislike of their own body in passing, do you join in as if body hatred is a shared experience to connect around? Overtly talking about your weight loss attempts and dislike of your own body is absolutely damaging to fat people, but so is communicating in a more covert way. Most higher weight people have spent years learning to pick up on even the most subtle evidence of weight stigma. This hypervigilance has been necessary for survival, and will also mean that fat clients pick up on your own dieting and body hatred even when you aren’t overtly naming it.  When we diet or restrict we are harming our fat clients. There isn’t a way around that. 

Harm is one of those words that can be kind of ambiguous and I want to be clear that what we are talking about here is not ‘just’ microaggressions, but actually putting our fat clients lives at risk. It is becoming more common to hear stories of medical providers who diagnose clients as fat instead of diagnosing their strep throat or ear infections; who miss a cancer diagnosis because they were so focused on weight loss; and who refuse life saving surgeries because they deem a client too fat for surgery all while suggesting clients have bariatric surgery. These are horrific situations and, while the details may be different, we are also putting fat clients' lives at risk in therapy. As someone who works with a lot of higher weight clients, I hear the stories of the therapist that encouraged weight loss and the client spiraled into a life-threatening eating disorder; of the therapist that encouraged a fat client to have bariatric surgery that resulted in life-threatening complications; of the therapist who talked so much about their own body hatred that their fat client felt hopeless about their own body and contemplated suicide. These experiences aren’t rare. If you aren’t hearing about them from your clients it’s because your office isn’t a safe place for them to talk about it. 

As a fat therapist myself, the violence I hear towards fat people in therapist communities is staggering. It’s as if so many therapists forget- or don’t care- that there are fat therapists reading and listening to what they are saying. I get harmed and sad anytime I encounter weight stigma amongst therapists, and I have the knowledge and skill to seek out care that is fat affirming and validating of my lived experience. I am terrified when I about all of the people in higher weight bodies who are seeking therapy and are met with such violence and erasure. I know for sure that therapists who are talking about fatness with such disgust and dismissiveness in therapist groups are also communicating that to their clients. Sadly, this kind of attitude doesn’t exist only in therapists outside of the eating disorder field. The fat hatred and promotion of weight loss exists within the eating disorder field as well. 

If you are a therapist working with clients, you are a therapist working with fat clients. You are a therapist working with clients with eating disorders. You are a therapist working with clients who have a dieting history, a desire for weight loss, a complicated relationship with food and their body. You are a therapist who occupies their own body in the room, has their own complicated relationship with food and your body and possibly your own history of dieting or an eating disorder. You are a therapist with power in the room and a therapist who has the capacity to enact harm and violence on your fat clients or to support their healing. 

The world is full of weight stigma and I am holding therapists to a higher standard. If you have not done your own work on your relationship with your body, have not explicitly embraced fat liberation, are not firmly rooted in an anti-diet framework, are not willing to stop dieting or suppressing your weight, are not educated on the intersection of anti-Blackness and anti-fatness, are not naming clearly that you do not encourage or support weight loss, are not working on unpacking your internalized weight stigma, are not speaking up and pushing back when you see weight stigma occur amongst therapists, and are not deeply aware of the ways that anti-fat bias puts fat peoples lives at risk, know that fat clients are not safe in your care and refer them elsewhere. 

As therapists we have a lot of work to do around many different issues. Most of us have experienced graduate school that tried to train the humanity out of us. We have been indoctrinated into oppressive systems and were never exposed to the liberatory frameworks we should have learned in grad school. Many therapists are now openly committed to social justice but fail to include fatness. If you aren’t including fatness in your social justice work it’s not intersectional and it’s not liberatory. During this fat liberation month, I hope that the therapist community will take a long look at themselves and identify the ways that the profession continues to cause harm both in the therapy room and in the field as a whole. 

As recently as 2018 the American Psychological Association released a stigmatizing and oppressive document steeped in anti-fat bias on how to “treat” higher weight people. Ask new therapists how many of them were subjected to Yalom’s “Fat Lady” with no critical analysis or naming of the violence the same way much older therapists were. Take a few minutes to read through some of the more popular books on CBT, ACT, and DBT and notice how frequently weight loss is used as an example of a treatment goal, food is talked about in reference to addiction or a “maladaptive coping strategy,” and how often more psychodynamic or psychoanalytically trained therapists talk about fatness as an attempt to be less sexually desirable in response to trauma that will change once the trauma is treated. We have a ton of work to do. 

In the various therapist spaces conversations about ethics are commonplace. Typically these conversations require a ton of nuance and discernment. Not once in a therapist group (unless it’s explicitly fat positive therapists) have I seen anyone mention how unethical it is to treat clients from a framework that supports weight loss. Not once I have seen anyone name how unethical it is to stigmatize and further oppress fat clients. The absolute truth here is that you are either working to be safe for fat people; or you are dangerous for us. You are either supporting our liberation or you are putting our lives at stake. 

When it comes to eating disorder posts and blogs they often center around a few different topics. They usually go something like: 

Are eating disorders biological? Genetic? Trauma based? Societal? A brain disease?

Don’t look at “underlying issues.”

Don’t blame parents.

Don’t blame society.

Weight restoration is all that matters.

“Evidence based treatment! Evidence based treatment! Evidence based treatment!”

Mandated treatment. 

Can someone with anorexia have decision making capacity? 

And on, and on, and on…

I have to say I’m feeling exhausted by all of them. Not because they aren’t important topics and questions, they absolutely are, but instead of conversations they end up being directives; instead of dialogue they end up being accusations; instead of space for nuance and complexity and unanswered questions they end up being presented as if there is a correct answer when there is not. Of course there is no way to include everything in any one blog or social media post, and I will exclude things here as well, but reducing topics that require nuance and space for complexity to a question and expecting an answer is a huge problem that leaves little room for discussion or for actual lived experience.  

Every time I read about these topics I want to scream “anorexia is not the only eating disorder!” It seems that eating disorders other than anorexia get left out of nearly every conversation about eating disorders and not only is anorexia not the only eating disorder, but eating disorders often overlap. People often struggle with symptoms or behaviors of more than one eating disorder at the same time, or at different times during their life. I want to ask people who say that cognitive state improves as weight goes up if they’ve ever sat with someone who purges and who’s anxiety and discomfort when they eat more and gain weight is so distressing that purging increases? We frequently are then holding space for someone vacillating between eating more and purging more or restricting more and purging less. It’s rarely as simple as gain weight, stay there for a while, and cognitive state will improve.  

Anyone who knows me knows that I am a firm believer in the importance of weight restoration (although I hate that terminology, but that’s a blog for another day). I believe in weight restoration because I do think that for many people it makes the eating disorder thoughts quieter, but I mostly believe in it because I don’t think you can heal from an eating disorder and still be actively participating in diet culture and anti-fat bias and if you’re suppressing your weight, you’re participating. So I believe in weight restoration partly for eating disorder recovery and mostly for liberation. 

But part of the problem with the debate around weight restoration is that it usually leaves out the impact of anti-fat bias and weight stigma. For people who recover into a larger body, how do you know that eating disorder cognitions are going to decrease? Maybe in a culture with so much weight based oppression, there are times that they increase and don’t decrease even as time passes? Maybe for some people weight restoration means that not only do their eating disorder cognitions increase, but that the people around them start sounding a lot like their eating disorder when they criticize their weight gain and praise weight loss. Do I think there is liberation found in no longer suppressing weight? Yes. Do I think that there are people who, for many wise and understandable reasons don’t have access to that liberation right now? Absolutely.

One of the most challenging things about eating disorders is that we don’t know how to predict who’s going to survive and who’s going to die from them. We don’t know who’s going to exist with their eating disorder and who’s going to heal and truly live. We have ideas and theories for how to predict and we have ideas about what protective factors there are, but ultimately, we don’t know. What we do know is that as heartbreaking as it is, some people are not going to survive their eating disorder. And what we do know is that some people don’t want treatment or don’t want to heal. We often refer to that as “part of the eating disorder” or a symptom of anorexia, and that is frequently true. 

I understand the argument that if the desire to not recover or seek treatment is coming from the eating disorder itself, then it shouldn’t be driving the decision making. And I think it’s way more complicated than that. I don’t want anyone to have their life rules written by an eating disorder and I also know that sometimes those rules, ironically, might be what helps someone to survive. They might be the only thing that allows someone to cope. They might be the only thing that anchors them to anything. They might be more tolerable than whatever trauma memories come up when the eating disorder isn’t ruling everything. 

I know that eating disorders can impact decision making. I also know that taking away someone’s autonomy around medical and treatment decisions can cause trauma that significantly impacts the possibility of healing. I wonder if people who argue that eating disorders prevent someone from having decision making capacity and that treatment should be mandated have ever sat across from someone who has endured forced treatment and now is terrified to share anything in therapy for fear that their therapist is going to mandate treatment again. There are times that mandated treatment helps and there are so many times it causes further harm and prevents someone from accessing treatment again. 

It’s literally an impossible question in many ways. When we have no way of knowing the future, how do we make decisions about how to support someone in the present? Do we value living over everything? Do we value autonomy? Do we value relationship and believe it’s what helps people heal? What if that takes too long? What happens when we risk the relationship to mandate treatment? Do we risk causing more trauma for the possibility of someone surviving? Do we recognize the amount of trauma living with an eating disorder already causes? Do we know for sure that weight restoration- particularly for those who recover into fat bodies- is going to improve cognitive state? Are we holding the impact of anti-fat bias when it comes to eating disorders? Of the culture? Of abuse and trauma and oppression and marginalization?

And for the love of all things, are we remembering that anorexia is not the only eating disorder? 

I long for conversations that consider these questions with nuance and complexity. I long for a space for providers and clients and activists and parents and advocates to be able to say “I don’t know.” Or to say “I disagree” without being attacked or told they aren’t an ethical provider or good enough supporter or the ‘right’ kind of activist or parent. I want us to recognize that lived experience matters- perhaps more than anything else. I am so eager to be able to have conversations that don’t come up with answers or agreement or consensus. I am not interested in finding ways to compromise values or ethics or hearing that only a small handful of treatments are “evidence based” when the truth is the evidence is severely lacking and many people have been harmed by these treatments. 

I so desperately want the eating disorder field to hold a liberatory framework for all of these conversations and all of the ways we show up. I want liberation to be centered because, when we aren’t centering it, we are settling and that’s not nearly good enough. And, I want the eating disorder field as a whole to recognize the hypocrisy of even talking about ‘weight restoration,’ or discussing mandated treatment, or holding one form of treatment above another, or asking what causes eating disorders when the major eating disorder organizations are still promoting weight loss, still allowing members to accept money from weight loss companies, and have refused to take a stand on fat liberation. When the major eating disorder organizations, and many eating disorder providers, are still contributing to the development of eating disorders I have little faith in their ability to have complex and nuanced conversations. If they can’t unanimously answer one question that has an easy answer- the support of fat liberation- how can they be trusted to hold space for questions that have no answers?

I’ve been in some form of recovery from my eating disorder for many years. I’ve gotten through pretty much every challenging food situation that has come my way. I’ve tolerated my body changing. I’ve embraced hunger and taking up space. And I don’t fast on Yom Kippur.

I know that I could fast and it wouldn’t trigger my eating disorder. I could fast and break the fast and wake up the next day and eat normally again. I appreciate all the articles I see this time of year by Jewish people who are struggling with an eating disorder or are early in recovery talking about why they don’t fast. These articles are so important and necessary in giving permission to others in similar situations to not fast on Yom Kippur. And the truth is, you don’t need an excuse or reason not to fast on Yom Kippur.

For me, I don’t fast on Yom Kippur as a way to honor a different time in my life. The time I almost died of anorexia. The time when smallness was what I valued above everything else. The time I denied hunger. The time that eating was much much harder than not eating. 

I know that Yom Kippur is about repenting and atonement. I know that it’s a day to reflect and pray and that it’s not supposed to be an easy day. And eating is easy for me now. Fasting would be harder. And I’m not going to fast. I’m not going to fast even though I’m not emaciated anymore. I’m not going to fast even though I’m not thin anymore. I’m not going to fast even though many weight biased people in the world would say it would be good for me to fast. 

I’m going to eat to honor the long lineage of people in my family who have struggled with restrictive eating and eating disorders. I’m going to eat to honor my ancestors who didn’t get to. I’m going to eat to acknowledge the work I’ve done to untangle the inter generational trauma and hopefully change things for the next generation.

I entered the world in a body that was not considered acceptable in my family because of its size. I was not given permission to eat as a child and I have fought hard to give myself permission to eat. I do not want something to take that permission away-even a holiday- even for one day. There’s been way too many days of fasting in my life already. I’m not intentionally doing another one. Eating is hard won. 

The G-d I pray to is not the G-d I learned about as a kid. That G-d, I was told, judged and balanced my good deeds and mistakes and based on which I did more of decided my fate for the year. The G-d I pray to now is a loving and compassionate G-d. She is not interested in judging me and She is not interested in deciding my fate based on how my year balances out. And She is certainly not interested in tipping my fate in one direction or another based on whether I eat or not. The G-d I pray to now will be proud of the work I’ve done to make eating easy and will know that the good I do in the world has nothing to do with the size of my body or whether I fast or not on Yom Kippur.

Rachel Millner (she/her), PsyD, CEDS, CBTP
Healing Relationship with Food and Body
[email protected]   |    215-932-9885
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